Oncological outcomes of operative treatment of subcutaneous soft-tissue sarcomas of the extremities

We reviewed the cases of sixty-two patients who had had a subcutaneous sarcoma to determine the effect of tumor and treatment-related variables on the rates of survival and local recurrence. Fifty-nine (95 per cent) of the patients had had an operation at another hospital before being referred to us. Twenty-nine (47 per cent) of the sixty-two tumors were high-grade, forty-two (68 per cent) were small (five centimeters or less), and thirty (48 per cent) were malignant fibrous histiocytomas. We followed a treatment strategy that consisted of repeat excision with the goal of obtaining wide margins. Excluding thirteen patients who had had a palpable local recurrence at the time of presentation, twenty (49 per cent) of forty-one patients who had had a marginal excision at another hospital had microscopic residual tumor on repeat excision. At a median of fifty-six months after the repeat excision, fifty (81 per cent) of the sixty-two patients had been continuously disease-free, one had no evidence of disease, eight had died of the disease, and three had died of other causes. The five-year rate of disease-free survival was 85 per cent (fifty-three of sixty-two patients). There were three local recurrences, all in patients who had had a marginal resection. No recurrences were noted in patients who had had a wide local excision of the tumor or of the previous operative field. Multivariate analysis revealed that a large tumor (greater than five centimeters), a marginal excision, and adjuvant radiation therapy were associated with a worse prognosis. Excellent rates of survival for patients who have a subcutaneous sarcoma, including those who have a large or high-grade tumor and those who have residual tumor following a previous operation, can be obtained with carefully planned operative treatment alone. We recommend operative excision or repeat excision with wide margins because of the high prevalence of residual tumor. Size is the most important tumor-related factor, and the operative margin is the most important treatment-related factor. The additional value of adjuvant radiation therapy remains unproved.     

The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma

Seventy-four patients who had a Ewing sarcoma of bone were managed with preoperative and postoperative chemotherapy and operative resection, with or without postoperative irradiation. The primary objectives of the study were to determine the histological response to preoperative chemotherapy in terms of the percentage of tumor necrosis and to assess the relationship between the histological response and the oncological outcome. The minimum duration of follow-up of the surviving patients who were continuously free of disease was five years. Sections of each operative specimen were examined, and the histological response to chemotherapy was graded semiquantitatively. Grade I indicated necrosis of 50 per cent of the tumor or less; grade II, necrosis of more than 50 per cent but less than 90 per cent; grade III, necrosis of 90 to 99 per cent; and grade IV, necrosis of 100 per cent of the tumor. Of the seventy-four tumors, forty-four (59 per cent) were exquisitely sensitive to chemotherapy and had complete (grade-IV) or nearly complete (grade-III) necrosis. In contrast, fourteen tumors (19 per cent) had little or no response to chemotherapy (grade I) and sixteen (22 per cent) had a moderate degree of necrosis (grade II). The histological response to preoperative chemotherapy (p = 0.0001), followed by the size of the tumor (p = 0.001), were the most important predictors of event-free survival. At five years, the rate of event-free survival was zero of fourteen patients who had had a grade-I response, six of sixteen who had had a grade-II response, and thirty-seven (84 per cent) of forty-four who had had a grade-III or IV response. The risk of local recurrence was most strongly associated with the operative margins; there were only four local recurrences (6 per cent) after sixty-seven resections with negative margins. Local recurrence may also have been influenced by the histological response and the use of local radiation. There were no local recurrences after operative treatment of six tumors that had been associated with pathological fracture. The histological response to preoperative chemotherapy and the size of the primary tumor are the most important clinical predictors of the outcome of operative treatment of non-metastatic Ewing sarcoma. These indicators should be used to identify patients who are at high risk for metastasis as such patients may be candidates for more intensive or novel therapies.     

Osteoma of the long bones and the spine. A study of eleven patients and a review of the literature

The clinical features, radiographic and histopathological findings, treatment, and results are described for eleven patients who were managed for an extracranial osteoma at our medical center between 1980 and 1993. Ten of the patients were initially seen because of dull, aching bone pain that had been present for two weeks to thirty years. Radiographs demonstrated single or multiple homogeneous, well defined, radiodense foci with smooth round or lobulated margins. The histopathological features consistently included uniformly dense, compact, cortical-like, mature lamellar bone. The preoperative diagnosis was unclear for all patients, and osteoma was rarely considered in the differential diagnosis. For four patients, a tentative diagnosis of osteosarcoma was made, and a wide excision was carried out in two of these patients. Marginal excision with less than three millimeters of normal tissue around the lesion was performed in most patients. None of the osteomas recurred, and ten patients had relief of the pain. Awareness of the clinical, radiographic, and histopathological features of osteoma, as described, is valuable for making a differential diagnosis and for distinguishing osteomas from other lesions.     

Treatment of infection with débridement and retention of the components following hip arthroplasty

Forty-two patients (forty-two hips) who had an infection following a hip arthroplasty were managed with open débridement, retention of the prosthetic components, and antibiotic therapy. After a mean duration of follow-up of 6.3 years (range, 0.14 to twenty-two years), only six patients (14 per cent) -- four of nineteen who had had an early postoperative infection and two of four who had had an acute hematogenous infection -- had been managed successfully. Of the remaining thirty-six patients, three (7 per cent of the entire group) were being managed with chronic suppression with oral administration of antibiotics and thirty-three (79 per cent of the entire group) had had a failure of treatment. All nineteen patients who had a late chronic infection were deemed to have had a failure of treatment. Débridement had been performed at a mean of six days (range, two to fourteen days) after the onset of symptoms in the patients who had been managed successfully and at a mean of twenty-three days (range, three to ninety-three days) in those for whom treatment had failed. Débridement with retention of the prosthesis is a potentially successful treatment for early postoperative infection or acute hematogenous infection, provided that it is performed in the first two weeks after the onset of symptoms and that the prosthesis previously had been functioning well. In our experience, this procedure has not been successful when it has been performed more than two weeks after the onset of symptoms. Retention of the prosthesis should not be attempted in patients who have a chronic infection at the site of a hip arthroplasty as this approach universally fails.     

Radiofrequency catheter ablation in type I atrial flutter: preliminary experience of 10 cases

Common atrial flutter results from macroreentry in the right atrium. Catheter ablation of slow conduction, between tricuspid annulus and inferior vena cava (TA-IVC) or tricuspid annulus and coronary sinus ostium (TA-CS os) has been reported to terminate and prevent recurrence of this arrhythmia. We reported 10 consecutive patients, 7 men and 3 women, who underwent radiofrequency catheter ablation of common atrial flutter. The mean age was 59.4 +/- 11.2 years (range 42-82 years). During the paroxysmal atrial flutter, all patients had palpitation, 4 had dyspnea on exertion, 3 patients had syncope and 1 patient had presyncope. The mean duration of symptoms was 5.7 +/- 4.9 years (range 0.5-13 years). Two patients had dilated cardiomyopathy, 1 Ebstein's anomaly and 1 chronic obstructive pulmonary disease. Four patients (40%) had history of atrial fibrillation (AF) before ablation. The mean cycle length of atrial rhythm was 257.2 +/- 36.6 ms. Ablation was done by anatomical approach and could terminate arrhythmia in 9 patients (90%), 7 from TA-IVC, 2 from TA-CS os without major complication. The mean number of applications was 20.4 +/- 16.9 and turned atrial flutter to normal sinus rhythm in 13.5 +/- 10.7 seconds. Fluoroscopic and procedure times were 38.4 +/- 31.4 and 157.2 +/- 68.8 minutes, respectively. During the follow-up period of 24.0 +/- 28.7 weeks, 2 patients had recurrent atrial arrhythmia, 1 atrial fibrillation and 1 atrial flutter type I, giving the final success rate of 70 per cent. All patients who had recurrence or failure had a history of paroxysmal AF before ablation. In conclusion, radiofrequency catheter ablation in atrial flutter type I, using anatomical approach, is an effective treatment to terminate and prevent this arrhythmia in short term follow-up. It may be considered as an alternative treatment in patients with atrial flutter who were refractory to antiarrhythmic agents.     

Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma

We report the long-term results of arthrodesis of the mid-tarsal and tarsometatarsal joints, performed for osteoarthrosis after dislocation with or without a fracture (seventeen patients [seventeen feet]), for primary degenerative osteoarthrosis (twenty-one patients [twenty-two feet]), or for inflammatory arthritis (two patients [two feet]). All forty patients (forty-one feet) had a severe loss of function because of pain. The average age of the patients who had primary degenerative osteoarthrosis was sixty years (range, twenty-seven to seventy-five years) and that of the patients who had post-traumatic osteoarthrosis was forty years (range, twenty-three to sixty-seven years); the two patients who had inflammatory arthritis were forty-four and seventy years old. Thirty-seven patients (thirty-eight feet; 93 per cent) were satisfied with the results of the procedure after an average duration of follow-up of six years (range, two to seventeen years). Union was achieved after 176 (98 per cent) of the 179 attempted arthrodeses, and only one of the three non-unions necessitated an operative repair. A skin slough developed in two patients, one of whom needed operative débridement. Five patients noted at least one prominent metatarsal head postoperatively, but none of these patients needed débridement because of abnormal callus formation. A stress fracture of the second metatarsal developed in three patients, but all three fractures responded to immobilization of the foot. An incisional neuroma developed in three patients, but none of these patients needed additional treatment. We believe that patients who have a severe loss of function due to osteoarthrosis of the mid-tarsal or tarsometatarsal joints can be managed successfully with tarsometatarsal or mid-tarsal arthrodesis, or both.     

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.     

Total-body skeletal muscle mass: evaluation of 24-h urinary creatinine excretion by computerized axial tomography

We retrospectively reviewed the results of operative decompression for peroneal nerve palsy in thirty-one patients who had been managed between 1980 and 1990. All patients had been managed non-operatively for at least two months after they had initially been seen. Intraoperatively, we found epineurial fibrosis and bands of fibrous tissue constricting the peroneal nerve at the level of the fibular head and at the proximal origin of the peroneus longus muscle. At a mean of thirty-six months (range, twelve to seventy-two months) postoperatively, thirty (97 per cent) of the thirty-one patients reported subjective and functional improvement and were able to discontinue the use of the ankle-foot orthosis. In contrast, only three of nine patients who had been managed non-operatively reported subjective and functional improvement (p < 0.01). Peroneal nerve palsy does not always resolve spontaneously; if it is left untreated, the loss of dorsiflexion of the ankle and persistent paresthesias can result in severe functional disability. Therefore, if non-operative measures do not lead to improvement within two months, we believe that operative decompression should be considered.     

Biliary dyskinesia: natural history and surgical results

Patients with biliary dyskinesia have symptoms consistent with biliary colic and an abnormal gallbladder ejection fraction (GEF) in the absence of cholelithiasis. Cholecystokinin hepatobiliary scan quantifies gallbladder function and may assist in selecting patients with acalculous biliary pain who would benefit from cholecystectomy. Seventy-eight patients with an abnormal GEF (< 35%) on cholecystokinin hepatobiliary scan without cholelithiasis were studied retrospectively. Patients were divided into groups based on diagnosis and treatment. In Group I, the patients who underwent cholecystectomy, 80 per cent (35 of 44) had complete symptomatic resolution whereas the remaining 20 per cent (9 of 44) had symptomatic improvement. Pathology reports demonstrated chronic cholecystitis in 95 per cent of specimens. Group II were patients with symptoms attributable to biliary dyskinesia, but did not undergo cholecystectomy. Persistence of symptoms was noted in 75 per cent (18 of 24) of patients whereas 25 per cent (6 of 24) had symptomatic resolution without any treatment. Group III consisted of patients with an abnormal ejection fraction who had improvement of symptoms after treatment for an alternative diagnosis (n = 10). These findings suggest that an abnormal ejection fraction does not always indicate gallbladder disease. Alternative diagnoses must be investigated and treated. Patients with persistent biliary type symptoms in combination with an abnormal GEF in the absence of other attributable causes can expect a favorable response to cholecystectomy.     

Operative treatment of fractures of the tibial plafond. A randomized, prospective study

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allg?wer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.     

Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip

We report the results of proximal femoral osteotomy that was performed to treat osteoarthrosis in twenty-three consecutive young adults (twenty-five hips) who had a mean age of thirty-eight years (range, eighteen to fifty-three years). The mean duration of follow-up was seven years (range, two to twelve years). With conversion to a total hip replacement as the end point, the rate of survival at twelve years was 67 per cent (95 per cent confidence interval, 37 to 88 per cent). Four hips (16 per cent) were converted to a total hip replacement at a mean of eight years after the osteotomy. For the patients who did not have conversion to a total hip replacement, the mean score for pain, according to the system of Merle d'Aubigné and Postel as modified by Charnley, improved from 3.4 points preoperatively to 5.1 points postoperatively, the mean score for walking ability improved from 3.9 to 4.7 points, and the mean score for range of motion improved from 3.2 to 4.2 points. These results compare favorably with those following other forms of operative treatment of osteoarthrosis of the hip in young adults. In addition, the osteotomy does not preclude subsequent replacement arthroplasty if one is necessary.     

Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging

The purpose of this study was to demonstrate that specialized magnetic resonance imaging provides an accurate assessment of lesions of the articular cartilage of the knee. Arthroscopy was used as the comparative standard. Eighty-eight patients who had an average age of thirty-eight years were evaluated with magnetic resonance imaging and subsequent arthroscopy because of a suspected meniscal or ligamentous injury. The magnetic resonance imaging was performed with a specialized sequence in the sagittal, coronal, and axial planes. Seven articular surfaces (the patellar facets, the trochlea, the femoral condyles, and the tibial plateaus) were graded prospectively on the magnetic resonance images by two independent readers with use of the 5-point classification system of Outerbridge, which was also used at arthroscopy. Six hundred and sixteen articular surfaces were assessed, and 248 lesions were identified at arthroscopy. Eighty-two surfaces had chondral softening; seventy-five, mild ulceration; fifty-three, deep ulceration, fibrillation, or a flap without exposure of subchondral bone; and thirty-eight, full-thickness wear. To simplify the statistical analysis, grades 0 and 1 were regarded as disease-negative status and grades 2, 3, and 4 were regarded as disease-positive status. When the grades that had been assigned by reader 1 were used for the analysis, magnetic resonance imaging had a sensitivity of 87 per cent (144 of 166), a specificity of 94 per cent (424 of 450), an accuracy of 92 per cent (568 of 616), a positive predictive value of 85 per cent (144 of 170), and a negative predictive value of 95 per cent (424 of 446) for the detection of a chondral lesion. Interobserver variability was minimum, as indicated by a weighted kappa statistic of 0.93 (almost perfect agreement). With use of this readily available modified magnetic resonance imaging sequence, it is possible to assess all articular surfaces of the knee accurately and thereby identify lesions that are amenable to arthroscopic treatment.     

Catheter ablation of incessant ventricular tachycardia

Emergency catheter ablation of ventricular tachycardia was performed in 22 patients. All patients had incessant ventricular tachycardia that persisted for > or = 12 h/day and was only transiently terminated by stimulation techniques, anti-arrhythmic drugs or cardioversion. Radiofrequency catheter ablation was carried out using entrainment criteria as well as endocardial activation mapping. Ventricular tachycardia was terminated in 91% of cases, one patient underwent map-guided surgery and the remaining patient was managed by anti-arrhythmic drugs. After the initial ablation procedure 3 of the 20 patients who could be acutely managed died in hospital: one patient in refractory heart failure 24 h following ablation, one patient suddenly 10 days following ablation on the ward and another patient 4 weeks following ablation because of septicemia. Four patients underwent elective implantation of a cardioverter-defibrillator because of inducible ventricular tachycardia, and another patient underwent elective map-guided surgery. Overall, 12 patients were discharged without any additional non-pharmacologic intervention; 5 of them were free of anti-arrhythmic drugs and 7 patients had previously received ineffective medication including continuation of amiodarone in 3 patients. These results indicate that radiofrequency catheter ablation may play a role in the treatment of patients with incessant ventricular tachycardia. Thus, non-pharmacologic management of incessant ventricular tachycardia is associated with a high hospital mortality rate especially in surgically treated patients. Catheter ablation using radiofrequency current is the preferred approach for acute palliation.     

The role of barium enema in colostomy closure in trauma patients

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.     

An investigation into variability in microvascular skin blood flow and the responses to transdermal delivery of acetylcholine at different sites in the forearm and hand

BACKGROUND: Inappropriate sinus tachycardia (IST) is a rare form of supraventricular arrhythmia. It can cause disabling symptoms and may be refractory to medical treatment. In symptomatic drug refractory patients, sinus node excision or total ablation of the sinus node with permanent pacemaker implantation was the only therapeutic option. Recently, radiofrequency (RF) modification of the sinus node has been reported to be an effective treatment for this condition. AIM: To present our experience with sinus node modification using RF energy in the management of IST. METHODS: Between 1989 to 1996 three patients (two females and one male), aged 28-36 years were diagnosed with symptomatic IST. All had failed multiple drugs and hence underwent sinus node modification using RF. In the first two patients, the site of RF application was guided by anatomical landmarks using fluoroscopy to localise the presumed most superior portion of the crista terminalis and also the earliest site of atrial activation. In the third patient, a 20 pole electrode catheter was used to map the crista terminalis and guide the ablation. Success was defined by 20-30% reduction in the heart rate with normal atrial activation sequence after ablation. RESULTS: The three patients described here had IST by clinical, electrocardiographic and electrophysiological criteria and were refractory to multiple antiarrhythmic drugs. The number of RF applications were 11, 15, and three applied at the site of earliest atrial activation for the control of heart rates. Patient 3 had a early recurrence at one month and underwent repeat sinus node modification (five RF applications). All three patients who underwent RF modification of the sinus node had a successful outcome. The procedure was uncomplicated and the patients remain asymptomatic during follow up (20, 12 and three months) with satisfactory control of heart rate, although one patient requires atenolol which was previously ineffective. CONCLUSIONS: RF modification of the sinus node is feasible and effective for IST, and should be the treatment of choice in patients refractory to medical therapy.     

Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up

We reviewed the cases of 108 patients with cervical spondylotic myelopathy who had been managed with anterior decompression and arthrodesis at our institution. Operative treatment consisted of anterior discectomy, partial corpectomy, or subtotal corpectomy at one level or more, followed by placement of autogenous bone graft from the iliac crest or the fibula. At the latest follow-up examination, thirty-eight of the eighty-two patients who had had a preoperative gait abnormality had a normal gait, thirty-three had an improvement in gait, six had no change, four had improvement and later deterioration, and one had a worse gait abnormality. Of the eighty-seven patients who had had a preoperative motor deficit, fifty-four had complete recovery; twenty-six, partial recovery; six, no change; and one had a worse deficit. The average grade according to the system of Nurick improved from 2.4 preoperatively to 1.2 (range, 0.0 to 5.0) postoperatively. A pseudarthrosis developed in sixteen patients, thirteen of whom had had a multilevel discectomy. Only one of thirty-eight arthrodeses that had been performed with use of a fibular strut graft was followed by a non-union. An unsatisfactory outcome with respect to pain was significantly associated with pseudarthrosis (p < 0.001). The development of complications other than non-union was associated with a history of one previous operative procedure or more (p = 0.005). Recurrent myelopathy was rare, but when it occurred it was associated with a pseudarthrosis or stenosis at a new level. The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention--that is, better preoperative neurological function was associated with a better neurological outcome. Anterior decompression and arthrodesis with autogenous bone-grafting can be performed safely, and is associated with a high rate of neurological recovery, functional improvement, and pain relief, in patients who have cervical spondylotic myelopathy.     

Detection of renal artery stenoses by MRI with surface reconstruction. Value in patients with chronic renal failure

BACKGROUND: The so called tachycardia-induced cardiomyopathy may develop as a complication of persistent abnormal high rates. It is especially common in patients who have either a permanent form of junctional reciprocating tachycardia or an ectopic atrial tachycardia. Radiofrequency catheter ablation has become established as an effective and safe treatment to eliminate both arrhythmias. METHODS AND RESULTS: Four children aged from 3 months to 8 years, who had incessant tachyarrhythmias and left ventricular dysfunction (shortening fraction of mean +/- SD, 21.7 +/- 1.2%) underwent radiofrequency catheter ablation. The youngest patient had permanent junctional reciprocating tachycardia caused by a left posteroseptal pathway. She was presented with severe heart failure that did not improve with digoxin and amiodarone. The other patients had palpitations and exercise intolerance. Two of them had an ectopic atrial tachycardia caused by a single atrial focus localized in the left atrial appendage apex and the orifice of the right atrial appendage respectively. The other patient had the permanent form of junctional reciprocating tachycardia caused by a right posteroseptal pathway. All four patients underwent one successful ablation. The average procedure mean time was 3.7 hours with an fluoroscopy time of 44 minutes. There were no complications. Subsequently shortening fraction improved progressively. After a mean follow-up of 21.7 months all patients are asymptomatic without medical treatment. CONCLUSIONS: Radiofrequency catheter ablation is the therapy of choice in children with either the permanent form of junctional reciprocating tachycardia or ectopic atrial tachycardia refractory to medical treatment. The tachycardia-induced cardiomyopathy is reversible after the elimination of the arrhythmia. The presence of tachycardia-induced cardiomyopathy is an indication for radiofrequency ablation even in small infants.     

A perspective on the ESVEM trial and current knowledge: catheter ablation for ventricular tachyarrhythmias

Although an effective and potentially curative technique for treating idiopathic ventricular tachycardia, map-guided transcatheter radiofrequency ablation is far from optimal for ventricular tachyarrhythmias in patients with advanced ischemic or other types of organic heart disease. First, this technique can be applied only to a minority of patients with structural heart disease, who can tolerate relatively long episodes of induced ventricular tachycardia necessary for mapping and successful ablation. Second, the success rate is lower and recurrence higher in patients with organic heart disease. Finally, for patients who lose consciousness during tachycardia or who present with prehospital cardiac arrest, transcatheter radiofrequency ablation is inappropriate as definitive treatment. At best, it is palliative and may be used to suppress relatively slow, frequent, or incessant ventricular tachycardias but does not obviate the need for other therapies such as cardioverter-defibrillator implantation or antiarrhythmic drug therapy.     

Design and evaluation of a portable rigid forced-air warming cover for prehospital transport of cold patients

Although villous lesions comprise only about 5 per cent of all adenomas, 40 per cent are premalignant. Complete colonic evaluation and resection of all villous lesions should be performed. The purpose of this study is to examine our experience with transanal excision and low anterior resection as treatment options for large villous adenomas of the rectum. A retrospective review of all cases of villous adenomas of the rectum at this institution from January 1991 to February 1997 was performed. A total of 16 patients were identified; fourteen underwent transanal excision and two underwent low anterior resection. The average lesion size was 5 cm, and 50 per cent extended proximal to 8 cm from the anal verge. Thirty-seven per cent (six patients) had villous lesions containing adenocarcinoma. Thirty-one per cent (five patients) have required treatment for residual disease noted within 6 months of resection. Twelve per cent (two patients) have received treatment for recurrent disease presenting 6 months after resection. The minor complications included two episodes of urinary retention. The serious complications included one perforation and one postoperative hemorrhage for a 12 per cent complication rate. In summary, large villous adenomas of the rectum can be removed by sphincter-preserving techniques with low morbidity and an acceptable recurrence rate.     

Anorectal melanoma--an incurable disease?

PURPOSE: This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence. METHODS: Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed. RESULTS: Overall five-year survival and disease-free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five-year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4-88) months, and all died of their disease at a mean of 29 (range, 5-98) months. CONCLUSION: Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.